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ENI 'ON W I ZIOZ 9Z ,d;S aWll PaAia3a� <br />Salt 9oaquin County 1868 East Hazelton Avenue <br />Stoon, CA 5205 <br />environmental Health Department Tel: (t09) 468-3420 <br />Fax: (209) 464-0138 <br />BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br />MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION ELL VIED <br />I. PROCEDURES TO BE PERFORMED: Check all that apply (see back for definitions) <br />Tattooing ody Piercing Mechanical Stud and Clasp Ear Piercing <br />Branding ®Permanent Cosmetics ENV <br />SEP 2 6 <br />II. REQUIRED REGISTRATION, PERMIT, OR NOTIFICATION FEES. Check all that apply, . `"11®v'c <br />I=Annual Body Art Practitioner Registration 3 Mechanical Stud and Clasp Ear Plercinq Notification <br />2CUAnnual Body Art Facility Permit <br />III. APPLICANT INFORMATION: <br /> <br />u?�,:,;olsr,.ns..[��.•'.n•G ,�.k.•,"c Y,ART.PRA 'TIONER.ONY� _ __. _.i„n. <br />Date of Birth: Gender: M or M (circle one) <br />Identifleation Type: Drivers LicenSp Other ``Iden fie Ion No.: 401 1 <br />Facility where Body Art Services will be Provided — A ® t <br />Evidence of Slxwmonth9 of <br />Bloodborne Pathogen Training. Submit Certificate <br />Hepatitis 8 Vaccination Status. Choose One and Submit Documentation <br />1Certiflcation of Completed Vaccination 3 Contraindicated for Medical Reasons <br />ZC=LaDoratory Evidence of Immunity 4®Vaccination Declination <br />IV �wne. Vr . ^i-wnnu /C\. 1—b-1, A.410-1 eke f -e — warmed—A <br />2, BUSINESS NAME: <br />Location address: suite: <br />eity: Statet zip: County: <br />Owner/ Contact: Phone/ Fax: <br />The undersigned hereby applies for a Body Art Facility Permit and/or Practitioner Registration and/or Mechanical <br />Stud and Ear Piercing Notification and agrees to operate In accordance with all applicable: state and local <br />requirements governing se ody art practices or practices governing mechanical stud and clasp ear piercing. <br />I hereby certify the a best of w and belief the etetemente mad® herein are true and correct. <br />Signature: Date: e5FPr �$'— !'Z <br />Print Name: / Title: mill <br />FOR OFFICE USE ONLY <br />Program (PE): Fees: Authorized by (KENS): Date Entered: <br />...•?.:.:.d,. r:i.'.:.. ...7 •i:. :f •:. .... :•..a..:».. ,. .. •.... •,., •�:a r �. ..:au•i:....c•.r... .. ... ... ... .. .�::•.. ;e:..:.,.,.,'�...:b:.io. Attrl o:..'i:.;1:;,.:., ..�,.:1',,.'. •. 6.11:.7•.. .. •.:N.i:,^al....:n :..:n'r: <br />t,/2'd 82TOt,9t,:Ol 82b8S28602 NOOW Elmo:WO8d 80:2T 2TO2-92-d3S <br />